Provider Demographics
NPI:1972548907
Name:GOTTLIEB, JERALD M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:M
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:7 OGLETHORPE PROFESSIONAL BLVD
Mailing Address - Street 2:UNIT 3
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3608
Mailing Address - Country:US
Mailing Address - Phone:912-224-5841
Mailing Address - Fax:912-352-4220
Practice Address - Street 1:7 OGLETHORPE PROFESSIONAL BLVD
Practice Address - Street 2:UNIT 3
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3608
Practice Address - Country:US
Practice Address - Phone:912-224-5841
Practice Address - Fax:912-352-4220
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPSY002692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA663871593AMedicaid
GA68BBGHMMedicare PIN
GAR57580Medicare UPIN
GAR57580Medicare UPIN